Provider Demographics
NPI:1710063953
Name:HARTZOG, KENNETH DELTON (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DELTON
Last Name:HARTZOG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 SOUTH 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4102
Mailing Address - Country:US
Mailing Address - Phone:256-546-4647
Mailing Address - Fax:256-546-4272
Practice Address - Street 1:249 SOUTH 6TH STREET
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4102
Practice Address - Country:US
Practice Address - Phone:256-546-4647
Practice Address - Fax:256-546-4272
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS357TA046152W00000X
GAOPT000791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059427Medicaid
T68932Medicare UPIN
AL0157960001Medicare NSC
AL000059427Medicare PIN